National Surveillance Estimates of Unintentional, Non-fire Related Carbon Monoxide Poisoning Jackie Clower, MPH Contractor, Air Pollution & Respiratory Health Branch June 13, 2011 National Center for Environmental Health Division of Environmental Hazards and Health Effects

CARBON MONOXIDE (CO)  Colorless, odorless gas  Produced due to incomplete combustion of hydrocarbons  Common routine sources:  Home heating & cooking appliances  Gas powered equipment  Motor vehicles  A leading cause of poisoning in the US

EPIDEMIOLOGY OF UNINTENTIONAL, NON-FIRE-RELATED EXPOSURES  Mortality & Morbidity  >20, 000 emergency department visits  ~450 deaths  Populations  Non-fatal: Children (<5 years), Females  Fatal: Elderly (>65 years), Males  Season  Winter  Region  Midwest  Northeast

HEALTH EFFECTS & PREVENTION  Non-specific flu-like symptoms:  Fatigue, dizziness, headache, confusion, nausea, vomiting  Collapse, coma, cardio-respiratory failure, & death  15−49% develop neuro-cognitive sequelae  Most cases:  Occur in residential settings  Preventable with installation of CO alarms

CO SURVEILLANCE Frequency of events Severity of outcome Preventability of exposures + Effectiveness of simple preventive measures =Critical Issue for Public Health Surveillance CDC developed a national surveillance framework for unintentional, non-fire related CO poisoning from several data sources

CO SURVEILLANCE FRAMEWORK Mortality Hospitalization Hyperbaric oxygen treatment Emergency department visits Poison center National Fire Protection Association Health Behaviors (e.g., presence of CO alarm at home) National Vital Statistics System – ~ 450 deaths annually (1999 –2004) Nationwide Inpatient Sample, 2007 – ? Nationwide Emergency Department Sample, 2007 – ? Hyperbaric Oxygen, 2009 – ? American Housing Survey, 2009 – 33.4% U.S. households with working CO alarm National Health Interview Survey, 2009 – 40.3% U.S. households with CO alarm National Poison Data System – ? (2000 – 2009) National Fire Protection Association, 2005 – 61,100 non-fire CO incidents

CO HOSPITALIZATIONS AND ED VISITS: METHODS Healthcare Cost and Utilization Project (HCUP)  Sponsored by Agency for Healthcare Research and Quality  Largest data repository of hospital discharges  Short-term, non-federal, general hospitals  Nationally representative samples are drawn

CO HOSPITALIZATION AND ED VISITS: METHODS  HCUP:  Nationwide Emergency Department Sample (NEDS)  Nationwide Inpatient Sample (NIS)  CSTE’s case definition used to classify confirmed, probable, & suspected cases  Rates were calculated with Census Bureau population estimates

CO HOSPITALIZATION AND ED VISITS: RESULTS  Highest rate of ED visits among those years (87 visits/million)  Highest rate of hospitalization among those ≥85 years (18 stays/million)  Females visited EDs more than males  Males more likely to be hospitalized  CO-related hospitalization cost was >$26 million

CO SURVEILLANCE FRAMEWORK Mortality Hospitalization Hyperbaric oxygen treatment Emergency department visits Poison center National Fire Protection Association Health Behaviors (e.g., presence of CO alarm at home) National Vital Statistics System – ~ 450 deaths annually (1999 –2004) Nationwide Inpatient Sample, 2007 – 2,302 confirmed cases Nationwide Emergency Department Sample, 2007 – 21,304 confirmed cases Hyperbaric Oxygen, 2009 – ? American Housing Survey, 2009 – 33.4% U.S. households with working CO alarm National Health Interview Survey, 2009 – 40.3% U.S. households with CO alarm National Poison Data System – ? (2000 – 2009) National Fire Protection Association, 2005 – 61,100 non-fire CO incidents

HYPERBARIC OXYGEN TREATMENT: METHODS  Database of hyperbaric oxygen treatments administered for severe CO poisoning  Undersea and Hyperbaric Medical Society (UHMS) physicians contribute data on patients receiving treatment  August January 2010: patient-level data were reported by 87 facilities in 39 states  Case definition: an individual treated with hyperbaric oxygen at a participating facility in the US

HYPERBARIC OXYGEN TREATMENT: METHODS  Panel of 38 questions:  Patient demographics  Treatment regimens  Circumstances surrounding poisonings  Example variables:  Number of others treated with hyperbaric oxygen in the same incident  Duration of exposure  Symptoms  Duration of loss of consciousness  % blood carboxyhemoglobin

HYPERBARIC OXYGEN TREATMENT: RESULTS  Among the 864 patients, most were:  White (54.3%)  Male (57.3%)  Aged years (43.5%)  75% exposed along with others  55% of patients were discharged after treatment  41% were hospitalized  10% of patients reported a CO alarm at their exposure location

CO SURVEILLANCE FRAMEWORK Mortality Hospitalization Hyperbaric oxygen treatment Emergency department visits Poison center National Fire Protection Association Health Behaviors (e.g., presence of CO alarm at home) National Vital Statistics System – ~ 450 deaths annually (1999 –2004) Nationwide Inpatient Sample, 2007 – 2,302 confirmed cases Nationwide Emergency Department Sample, 2007 – 21,304 confirmed cases Hyperbaric Oxygen, 2009 – 552 cases American Housing Survey, 2009 – 33.4% U.S. households with working CO alarm National Health Interview Survey, 2009 – 40.3% U.S. households with CO alarm National Poison Data System – ? (2000 – 2009) National Fire Protection Association, 2005 – 61,100 non-fire CO incidents

POISON CENTER CALLS: METHODS  Nationally, 61 Poison Centers upload call data to the National Poison Data System (NPDS)  2.2 million reports annually  Includes 36 million reports over last 30 years  Case definition: A call:  Regarding a human CO exposure  Coded as “unintentional” exposure  Example variables:  Demographics  Call type: informational vs. exposures  Clinical effects: symptoms  Exposure site  Level of care  Outcome

POISON CENTER CALLS: RESULTS  68,316 (23 calls/million/year) CO exposure calls to US poison centers from  28% of calls was regarding persons <18 years (18,896)  50% (34,356) of women & 44% of men (30,257) reported being exposed  235 deaths captured  NPDS provides data regarding CO exposed populations who would not be captured by administrative health records  53.7% (36,691) managed at a healthcare facility  45.1% (30,798) managed onsite & not otherwise identified

CO SURVEILLANCE FRAMEWORK Mortality Hospitalization Hyperbaric oxygen treatment Emergency department visits Poison center National Fire Protection Association Health Behaviors (e.g., presence of CO alarm at home) National Vital Statistics System – ~ 450 deaths annually (1999 –2004) Nationwide Inpatient Sample, 2007 – 2,302 confirmed cases Nationwide Emergency Department Sample, 2007 – 21,304 confirmed cases Hyperbaric Oxygen, 2009 – 552 cases American Housing Survey, 2009 – 33.4% U.S. households with working CO alarm National Health Interview Survey, 2009 – 40.3% U.S. households with CO alarm National Poison Data System – 68,312 exposure calls (2000 – 2009) National Fire Protection Association, 2005 – 61,100 non-fire CO incidents

SUMMARY AND CONCLUSIONS  These analyses expand CO surveillance to include:  Most comprehensive, recent national estimates of ED visits & hospitalizations  Most detailed information on patients treated with hyperbaric oxygen  First summary that includes a 10-year period of poison center calls  Findings from this surveillance framework are critical for prevention efforts as the results contribute to a better understanding of CO poisoning

ACKNOWLEDGEMENTS: Shahed Iqbal Jeneita Bell Fuyuen Yip For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone: CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Environmental Health Division of Environmental hazards and Health Effects